Abstract

Objective: Among older adults in the US, post-acute care (PAC) is often necessary following a hospital stay. This PAC commonly occurs in skilled nursing facilities (SNFs) and is paid for by Medicare, the government-funded health insurance for those over age 65. Since implementation of the Affordable Care Act, hospitals have become more responsible for the PAC that Medicare patients receive, including financial penalties for readmissions. The purpose of this research was to understand the experience of patients during the hospital discharge planning and SNF placement process, including the information patients use to make decisions, which factors they view as important in making their selection, and barriers and facilitators to the overall process.

Data and methods: We interviewed 97 SNF patients and/or their family members in five cities in the US. We recruited three SNFs within each market (two in the smallest market), and in each facility conducted semi-structured open-ended interviews with approximately seven previously community-dwelling, newly-admitted patients discharged from a hospital. These interviews were recorded, transcribed, and qualitatively coded to identify underlying concepts and themes.

Results: Despite different reasons for hospitalization and hospital lengths of stay, most respondents reported that they were required by hospital discharge planners to make decisions regarding SNF placement the day before their hospital discharge. Respondents generally received a list of SNF options which included only the names and addresses of facilities. This list was sometimes limited by location to just a few choices, but many respondents reported receiving a list of every facility in their city (i.e. several pages of facilities). In most cases, hospital staff were minimally involved in the decision-making process, but respondents reported appreciating such help when it was received. Common predictors of patients’ decisions included location (not surprising given that the address was often the only information patients were given) and previous experience (either a prior stay or knowing others who had prior stays). Some respondents reported relying on decision-making support from their family and friends; indeed, respondents without involved family seemed to have more difficult and stressful experiences. Most respondents reported being satisfied with their placement, but many stated that they would have been willing to travel farther to a higher quality facility or one recommended by their doctor. Many described the process as overwhelming, stating that they did not know where or how to get help. Despite known differences in how hospitals and SNFs collaborate, patients’ experiences in the discharge process were very similar.

Policy implications: SNF placement is a stressful transition, occurring at a time when patients are physically vulnerable, and often without significant help or guidance from experienced professionals like hospital discharge planners. Most patients select a facility based on its location, simply because they are provided with no quality information or advice. Hospitals are increasingly responsible for the outcomes experienced by patients post-discharge, yet the discharge planning process remains rushed and chaotic. Hospitals could likely reduce readmissions and other adverse outcomes by helping patients choose better quality facilities most suited to their clinical needs.

Slides